A Rare Case of Non-puerperal Acute Uterine Inversion.

Abstract

A forty-year-old female hailing from Raigad presented in casualty on 14 Jan 2011 at 6.40 pm with something coming out per vaginum for the last 4–5 days, backache, abdominal pain, and a foul odor discharge per vaginum. Her last menstrual period was on 9 Jan 2011. Her periods were relatively heavy; however, she had not sought consultation for the same. There were no other menstrual, bowel, or bladder complaints. She was married for 26 years and had four vaginal deliveries; the last child was 10 years old. Her past medical, surgical, and family histories were not of clinical relevance. On systemic examination, she was conscious and cooperative, but markedly pale with a pulse rate of 78/min, blood pressure of 100/60 mmHg. On per abdomen examination, the abdomen was soft; there was mild tenderness in the hypogastric region. On per vaginum and per speculum examination, a huge mass of 10 by 10 cm size was seen to have prolapsed from the vagina with a 4-cm-sized gangrenous area on the cervix with clear margins with maggots and foul odor. The mass could not be reposited. The cervical opening was not visualized. However, there was a small dimple at the tip of the necrosed mass, mimicking the ‘‘os.’’ Bilateral fornices were tender. There was no evidence of cystorectocele or vaginal or parametrial involvement. A provisional diagnosis of acute inversion of the uterus with septicemic shock was made. On per rectal examination, the uterus could not be felt. Her laboratory investigations revealed hemoglobin of 5–6 g % with leucocytosis. She was immediately started on higher antibiotics and three units of blood were transfused, and her condition stabilized with IV fluids and analgesics. An abdominal sonography was done, which revealed a prolapsed uterus with normal renal parameters. The patient was treated with daily betadine dressing and with subsequent corrective surgery. Examination under anesthesia confirmed that the dimple on the necrosed mass was not the cervix as the uterine sound could not be negotiated through it. The cervical opening was not seen. Reposition of the mass was not possible. Anteriorly, the bladder was reflected behind; however, the fundus of the uterus was not palpable. The diagnosis of acute inversion of the uterus was confirmed. A thick fibrous circumferential band near the vulva was suggestive of the obstructive ring through which the fibromyoma attached to the fundus (at the dimple), and must have incarcerated leading to necrosis of the prolapsed fibroid. The fibroid was enucleated from the fundus. The fibrous ring at the cervix could not be cut effectively so as to conserve the uterus. So, with regards to the age of the patient, parity, and complications, vaginal hysterectomy was performed. Her postoperative course in the ward was uneventful. She was given intravenous ferrous sucrose injection and Kulkarni K. K. (&), Lecturer Ajmera S. K., Lecturer Terna Medical College, Nerul, Navi Mumbai, Maharashtra, India e-mail: krantiphadnis@gmail.com The Journal of Obstetrics and Gynecology of India (September–October 2014) 64(5):364–365 DOI 10.1007/s13224-012-0294-x